Transcription of Prior Authorization Request Form–OUTPATIENT
1 Prior Authorization Request Form OUTPATIENTP lease fax to: 1-800-931-0145 (Home Health Services) 1-866-464-0707 (All Other Requests) | Phone: 1-888-454-0013*Required Field please complete all required fields to avoid delay in processingNote: In an effort to process your Request in a timely manner, please submit any pertinent clinical information ( progress notes, treatment rendered, test/lab results or radiology reports) to support the Request for services. Any Request for a non-contracted provider must include documentation to substantiate the reason for the Request . (When all required information has been submitted we will complete your Request within 5 business days.)
2 Expedited defined as danger to a member s health if not provided within 72 hours. Please explain: Member Information:*Member Name:*Member DOB: / /* Member ID:*Date of Service: / / Requesting Provider Information:*PCP/Requesting Provider:Contact Person:*Phone #:*Fax #:Referring to (servicing) provider information: if below fields are not answered, Cigna-HealthSpring will automatically assign Cigna-HealthSpring s participating provider network to the member:*Servicing Provider: Non-contractedTax ID #: NPI#:Contact Person:*Phone #:*Fax #:*Facility: Non-contractedTax ID #: NPI#:Contact Person:*Phone #:*Fax #:If requesting a non-contracted provider/facility, please explain why:* Type of Service.
3 Please check only one of the boxes: ASC Elective Inpatient Admit MRI/MRA/CT PET PT/OT/ST Cosmetic/Reconstructive Elective Outpatient Surgery Office Procedure Transplant Evaluation DME Medication Prosthetics/Orthotics Home Health Ambulance Other _____ _____ Clinical Information:*Diagnosis Code: Diagnosis: *Procedure/Service Requested: CPT Code: HCPCS Code:Procedure/Service Description:Number of visits: Duration:Frequency of visits: Number of previous visits:*Is supporting Clinical Information Attached? Yes No - Please summarize clinical information belowINT_13_11381 0924201328
